Mount Alvernia Hospital

Pre-Admission - Online submission

Dear Valued Customer,

In order to help us expedite the admission process, we would appreciate it if you could kindly complete the information below and send the form to us at least one day before your admission.

Patient's Particulars
Name	: * As in Identity card (NRIC), Passport or employment pass
Country of Residence	: *
Race	: *
Sex	: *
Address	:
	:
	:
Postal Code	:
Tel. No	: (Home)
	: (Mobile)
NRIC Type	:
NRIC/Passport No.	: *

Date of Birth	: *
Nationality	: *
Religion	:
Marital Status	: *
Date of Admission	: * click on the calendar to choose date
Occupation	:
Email Address	:

Next of Kin's Particulars (Immediate Family Members above 21 years of age)
Name	: As in Identity card (NRIC), Passport or employment pass
Relationship	:
Address	:
	:
	:
Postal Code	:
Sex	:
Tel. No	: (Home)
	: (Mobile)
NRIC Type	:
NRIC/Passport No.	:
Occupation	:

Pay by Medisave?	Yes No

Medisave Account Holder's Information
Name	: * As in Identity card (NRIC), Passport or employment pass
Patient is My	: *
Address	: *
	:
	:
Postal Code	: *
Sex	: *
Tel. No	: (Home)
	: (Mobile)
NRIC Type	:
NRIC/CPF No.	: *
Occupation	:

[Fill in only if applicable]
Name	: As in Identity card (NRIC), Passport or employment pass
Relationship	:
Address	:
	:
	:
Postal Code	:
Sex	:
Tel. No	: (Home)
	: (Mobile)
NRIC Type	:
NRIC/CPF No.	:
Occupation	:

Operation's Information
Name of Doctor	:
Name of Operation	:
Date of Operation	: click on the calendar to choose date
Time of Operation	: :


Accomodation Type
Ward Type	:
Note: We will be able to confirm the availability of room type only at the time of your admission. This is due to the uncertainty of patients' discharges and emergency admissions.


Remarks / Any Other Request